Provider Demographics
NPI:1245771393
Name:RUSSELL, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 NE 13TH ST
Mailing Address - Street 2:PROSTHETICS DEPARTMENT
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5007
Mailing Address - Country:US
Mailing Address - Phone:405-456-5656
Mailing Address - Fax:405-456-1532
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:PROSTHETICS DEPARTMENT
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-5656
Practice Address - Fax:405-456-1532
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist